Knowledge Translation (KT) and Health Technology Reassessment (HTR): Unravelling the Black Box Rosmin Esmail, PhD Candidate Dr. Tom Stelfox Dr. Fiona Clement University of Calgary April 15, 2019 CADTH Symposium 2019
Disclosure We have no actual or potential conflict of interest in relation to this topic or presentation.
What is the problem? Underused & highly beneficial, clinical- and High cost-effective Value Low Value Overused/misused & unnecessary, NOT clinical- and/or cost-effective
Why is this a problem?
How big is the problem?
Health Technology Reassessment (HTR) Structured, evidence-based assessment of the medical, • economic, social and ethical impacts of a health technology (e.g., drug, device, test, procedure, etc.) currently used in the healthcare system , to inform its optimal use in comparison to its alternatives (Noseworthy & Clement, 2012)
Conceptual model for HTR (Soril et al., 2017)
Clarifying Terminology Disinvestment: The processes of (partially or completely) withdrawing health resources from currently funded areas that provide little benefit for their cost (Elshaug, 2009) De-implementation: use of low-value care is reduced or stopped in a planned process (van Bodegom-Vos, 2017) De-adoption: discontinuation or rejection of a clinical practice after it was previously adopted (Rogers, 2003).
Outputs: increased use or adoption, decreased use, no change, de-adoption of the technology Outcomes: achieving the change, not achieving the change, remaining at status quo
So how can we mobilize HTR outputs? Field of KT KT has been used effectively to implement new interventions into clinical practice Can it be used for HTR?
Understanding Knowledge Translation
Terms for Knowledge Translation
KT has Many Names Knowledge management, knowledge mobilization, K*… Also known as effectiveness research, patient oriented research UK: implementation science or research utilization US: dissemination, diffusion, research use, knowledge transfer and uptake Canada: knowledge transfer and exchange, and knowledge translation
CIHR definition (part 1) Knowledge translation is a dynamic and iterative process that includes the synthesis , dissemination , exchange & ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the healthcare system.
CIHR definition, (part 2) This process takes place within a complex system of interactions between researchers and knowledge users which may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user (Graham, 2010).
Why Study it? Mechanism for determining how the two are linked How KT approaches can be used in the translation of HTR outputs Leading to optimal care for patients Fewer wasted resources Illuminate the understanding of the KE and utilization function of HTR model
Esmail R et al, 2018 Knowledge translation and health technology reassessment: identifying synergy. BMC Health Services Research 201818:674https://doi.org/10.1186/s12913-018-3494-y
Barriers and Facilitators to KT in the context of HTR WHO Category* Barriers Facilitators Climate and Context Physicians are reluctant to dismiss Use of clinical champions outmoded devices Linkage and Exchange Lack of a well planned strategy for Broad and early stakeholder implementation that engages all engagement stakeholders Research Evidence, HTR process, Lack of relevant evidence of the Good evidence base for the resources/timelines technology itself identification and recommendations Role of Researchers and HTR Difficulty in communicating with a Capacity building in KT and change variety of audiences management Role of Stakeholders, Knowledge Lack of resources and human Decision makers need to understand users, and the health system in resources to support HTR the HTR process and provide HTR, skills and expertise support *World Health Organization’s classification of barriers and facilitators, WHO, 2012)
PhD Research Question Employing a health systems perspective, this project will study and determine how KT approaches are used to translate HTR outputs to achieve the desired outcomes?
Methodological Approach Multiple methods Systematic review of KT Theories, Models, Frameworks (TMFs) Modified Delphi Process for expert validation (underway) Key informant interviews
What is a Theory, Model, Framework? Theory: a set of analytical principles or statements designed to structure our observation, understanding and explanation of the world Model: a deliberate simplification of a phenomenon or a specific aspect of a phenomenon Framework: usually denotes a structure, overview, outline, system or plan consisting of various descriptive categories Nilsen P , 2015
Many KT theories, models, frameworks Tabak et al (2012)-61 dissemination and implementation research theories, models, and frameworks Locker et al (2015)-51 classification schemes (23 taxonomies, 15 frameworks, eight intervention lists, three models and two other approaches) on KT interventions that could be used to integrate evidence into practice Milat et al (2017)-found 41 different frameworks and models from 98 papers with a focus on research translation frameworks Strifler et al (2018)-limited to models, theories and frameworks used in cancer and chronic disease management and prevention, searched 305 KT theories, models and frameworks, and identified 159 articles that met the inclusion criteria of the review Identified 26 full-spectrum KT theories, models, frameworks
Full-Spectrum TMF Consist of all four KT phases: planning/design (identifies a knowledge gap, engages stakeholders, develops an intervention), implementation, evaluation, and sustainability/scalability Strifler et al, 2018
Full-Spectrum KT Theories, Models, Frameworks 36 Full-Spectrum KT Theories, Models, Frameworks Esmail et al (unpublished, 2018)
Internal Committee Review of 36 TMFs 3-Round Modified Delphi Process (2 HTR/KT experts, 2 KT experts, 1 HTR expert) Third Round-Application of criteria: Face validity (KT theories, models, or frameworks that are common and well-known should be included) Active KT theories, models, or frameworks (passive KT theories, models, or frameworks were excluded) Feasible to apply to take something out of practice Pragmatic (theoretical KT theorises, models, or frameworks were excluded) Specific (vague or those that were not prescriptive were excluded) Could build on other KT theories, models, or frameworks but needed to be generic rather than for a specific context Easily understood and practical
Potential List of 16 KT TMFs for HTR Classic Theory=1 Diffusion of Innovations (Rogers, 3rd Edition, 1983) Frameworks=2 Consolidated Framework for Implementation Research (CFIR) (Damschroder, 2009) Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) (Glasgow, 1999) Fits both Model/Framework=1 Evidence-Driven Community Health Improvement Process (EDCHIP) (Layde, 2012) Process Models=12
Potential KT Process Models for HTR KT Models Stages of Research Evaluation (Nutbeam, 2006) Knowledge-to-Action (KTA) (Graham, 2006) Quality Implementation Framework (Meyers, 2012) Western Australia (WA) Health Network Policy Development and Implementation Cycle (Briggs, 2012) Collaborative Model for Achieving Breakthrough improvement (Institute for Healthcare Improvement, 2003) Healthcare Improvement Collaborative Model (Edward, 2017)
Potential KT Process Models for HTR KT Models Co-KT framework (Kitson, 2013) Plan-Do-Study-Act (PDSA) Cycles (Deming, 1986) A Staged Model of Innovation Development and Diffusion of Health Promotion Programs (Oldenburg, 1996) CollaboraKTion framework (Jenkins, 2016) KT framework for Agency for Healthcare Research and Quality (AHRQ) patient safety portfolio and grantees (Nieva, 2005) Design Focused Implementation Model (Ramaswamy, 2018)
Modified Delphi Process 22 International Experts (11 KT and 11 HTR) Countries: Canada, US, UK, Australia, Germany, Spain, Italy, and Sweden Round 1: Survey of 16 KT Theories, Models, Frameworks (Jan to March 2019)
Survey Questions for each KT Theory, Model, Framework Familiarity Logical Consistency/Plausibility Degree of specificity Accessibility Ease of use HTR Suitability
Next Steps Complete analysis of Round 1 Round 2: Key Informant Interviews with experts Identification of key constructs/attributes/elements of a KT theory, model, or framework for HTR
Acknowledgments Supervisors: Dr. Fiona Clement Dr. Heather Hanson Committee members: Dr. Jayna Holroyd-Leduc Dr. Daniel Niven
Rosmin.esmail@ucalgary.ca
Is Health Technology Reassessment Clinically Relevant? CADTH – April 15, 2019
Objective – Tell You a Clinical Story of HTR Patient case to ground us in clinical reality Share lessons learned Passive diffusion of knowledge is ineffective Focus on reproducible science Test effectiveness
Lesson #1 Passive Diffusion of Knowledge is Ineffective
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